Early last year, a 20-year-old Miami University student named Reid Rupp was treated for a severe facial injury from a bicycle accident. The Rupps chose Miami Valley Hospital in Dayton because it was in their health insurance plan network. However, unbeknownst to them, the plastic surgeon who operated on Reid was not in the plan’s network. Subsequently, the family received a surprise hospital bill of $17,000 that they could not afford to pay.
Sadly, the Rupps’ situation is not at all unusual. In fact, surprise medical billing has become more and more common. Patients in Ohio and across the nation continue to be billed after the fact for unknowingly receiving out-of-network care within in-network hospitals.
A recent UHCAN survey found that 1 in 3 privately insured Ohio adults have received a surprise bill in the last 12 months. Data shows that unanticipated out-of-network care has occurred in roughly 1 in 5 emergency visits and in 1 in 10 elective inpatient visits to in-network hospitals. The vast majority of those who receive out-of-network surprise bills indicated they couldn’t afford to pay and didn’t know the provider was out of their network at the time of care.
Fortunately, the Ohio House of Representatives is considering much-needed action on surprise billing. Rep. Adam Holmes, who represents Guernsey and Muskingum counties, has introduced House Bill 388, which protect Ohioans from surprise bills while also helping them avoid higher premiums due to increased unanticipated out of network care costs.
HB 388 would ensure that out of network providers are paid a fair, reasonable market rate. The bill would also offer parties the opportunity to dispute a rate they feel is inaccurate, structuring the appeal process as a default to avoid unnecessary costs, delays and bureaucracy to Ohio’s health care system.
Surprise medical bills do not arise out of disagreements, they arise because a market failure allows certain medical specialists to remain outside of Ohioans’ insurance networks and bill patients whatever they want. With 8 out of 10 Americans supporting legislation to protect individuals from high medical bills, Ohio is well positioned to fix this market failure through regulation.
Health plans negotiate prices with in-network providers to keep health care costs low while guaranteeing a flow of patients for providers. But certain doctors – such as anesthesiologists, radiologists, pathologists, and emergency room doctors – are guaranteed a steady volume of patients merely by having privileges in in network hospitals. As a result, many stay out of network so they are free to bill Ohioans whatever they want – sometimes more than 5 times the price Medicare pays.
This problem has been further exacerbated by the involvement of private equity and investment companies. About 65% of U.S. hospitals outsource emergency services to management firms backed heavily by private equity and venture capital interests. Last month, the U.S. House launched a bipartisan investigation into private equity firms that own physician staffing companies to determine whether they use out-of-network billing as a strategy to drive up their pay rates. Private investors understand that their profit margins are on the line and are pushing hard to defeat legislation in Congress to fix this problem.
Around the country, state lawmakers advancing laws to protect their constituents from surprise medical bills that are crippling so many of our families. Through HB 388, Ohio could help to lead the way.
This month, Reid Rupp’s mother, Lisa, was among those who submitted testimony to the Ohio House Finance Committee in support of the bill.
"The plastic surgeon who operated on Reid did not accept any insurance and charged rates well above what similar surgeons in the region charged for the same services," Lisa Rupp recalled Nov. 13. "If we had known, we would have chosen another doctor, another hospital, if necessary. But we were never told the doctor was out of network. We never had the opportunity to make an informed decision."
If HB 388 becomes law, other Ohio families in the Rupps’ situation will have the opportunity make an informed decision. They deserve that chance.
Miranda Motter is president and CEO of the Ohio Association of Health Plans.